Conversation: ‘Therapy with a plug on it’
Dr Kate Anthony in conversation with Paul Daly
Dr Kate Anthony, BSc, MSc, DPsych, FBACP is co-founder and CEO of the Online Therapy Institute. She is a Consultant and Fellow of the British Association for Counselling and Psychotherapy (BACP) and also a Specialist Advisor for Online Coaching for the BACP.
Paul: Thank you very much for agreeing to do this interview, Kate. You’re a pioneer in the development of online therapy training. What drew you to this area?
Kate: I have always been a fan of technology in general, then in the last year of my MSc at Greenwich University I broke my leg severely and was housebound. I spent time in chat rooms to take my mind off the pain and entertain myself – then realised when people knew my temporary disability situation, they were taking time off work to spend with me to help. I found it incredibly therapeutic and decided that I probably wasn’t the only person experiencing that. From there I chose it as the topic for my final thesis, as online therapy has existed since the mid-1990s.
Paul: Yes, in an onlinevents.co.uk (2014) interview that I watched, you mentioned the therapeutic benefit for yourself of being online following an accident. Could you say more about that either from your own experience or from the research?
Kate: It’s convenient, the research shows that it is equally effective to traditional ways of working off-line, and it gives the client autonomy over their sessions to fit what works for them. It’s also cost-effective. Cyberpsychology is a fascinating subject, and I love seeing clients design their therapy journey as to what would be best for them.
Paul: When you say ‘clients design their therapy journey’, what have you in mind?
Kate: The client can choose which or how many online sessions to have, as it suits their lives. So, while in-room sessions may be able to take place in the future, as well as these, there can be a switch to any other technology as convenient or desired (email or blog journaling as a feature of the designed therapeutic process, for example). Blending technologies into a therapy service is called omnichannelled therapy.
Paul: I’ll come back to that. You mentioned earlier that online therapy began in the mid- 1990s – though many of us were probably not aware of it at the time. Online therapy has gone through quite a lot of development since then, as you have outlined in your Covid-19 Telehealth course ‘Moving your practice online’, which you generously made available to practitioners on a pay-what-you-can basis at the beginning of the pandemic. What kind of feedback have you had on this course?
Kate: I’m pleased to say it has been universally helpful around the globe – at the time of this interview we have trained 12,470 practitioners, which is heartening. I felt it a privilege to be in a position to help quickly at the start of the crisis.
Paul: That’s an amazing number. Think of all the clients that have been reached because of this, and that are still being reached. Can I ask you about your longer course, the Online Therapy Institute’s Certified Cyber Therapist credential? What are the main areas covered in that course?
Kate: The course is designed to meet all of the BACP competences for working online, but focuses on theory, ethics and practice – all illustrated with a continuous case study using the main technologies of email, chat, telephone, and video work. We also cover virtual reality, GDPR, business building and marketing. We have a version for practitioners working with young people as well, with specialist attention to legalities.
Paul: That is a lot. I imagine it’s only a matter of time before online therapy forms part of mainstream therapy training – or maybe that’s happening already in different parts of the world?
Kate: Recent research during lockdown shows that 67% of practitioners want this to be part of core training, but we’re not quite talking mainstream yet anywhere apart from Kosovo, which had no mental health services until Dr Stephen Goss and I went there to help set up an online service years ago.
Paul: The irony is that traditional therapy training has been delivered online during the pandemic but not online therapy training by traditional therapy training providers. Can I ask you what kind of issues in online therapy people are presenting with during the pandemic, and if they have changed since before March of this year?
Kate: The issues remain the same, with an added element of ‘wow, look what’s happening to us all’. It’s rare that clients and practitioners alike are affected by global phenomena.
Paul: Yes, there was an article by Gary Greenberg (2020) in The Guardian in April, entitled “Therapy under lockdown: ‘I’m just as terrified as my patients are’” which made a similar point.
Kate: It’s a shame that people don’t realise that training answers all this anxiety. Many practitioner problems come from expecting the work to replicate a traditional session – it doesn’t. It’s a new way of working, with new theory and ethics, as well as practice.
Paul: Yes, and I think it’s true to say that online therapy has been growing for some time even before the pandemic. Why is this?
Kate: Because this is how society works now; we are all dedicated to the small computers we carry around with us in our pocket (called smartphones). Communication between humans made a massive shift when the internet became viable for everyone, and in particular the written word via text messages. The concept of spending time travelling to speak to a stranger intimately for 50 minutes is simply out of date. The future clients and practitioners will be experiencing this also, and so for them the concept of online therapy will be totally natural.
Paul: And yet the concept of ‘therapy with a plug on it’ – to quote that witty description you used in an onlinevents.co.uk (2014) interview – is for some people alienating, and some even see it as dehumanising. What’s your response to those concerns?
Kate: There will always be some therapists who can’t get past the technology to see it’s just a form of communication between human beings. If the clients want it, who are we to deny them the service just because of our own issues with technology? We’d be using smoke signals if we didn’t have the technology – the human ability to adapt is amazing.
Paul: What would you say are the strengths and weaknesses of the various online therapies?
Kate: This is very subjective – many of my trainees are discovering or rediscovering the beauty of creative writing via email. My personal favourite is using chat rooms as it combines the spontaneity of a live session with the benefits of being at a distance. Telephone has also seen an upturn, at least on a check-in basis with clients. Video works well done by trained professionals, although many struggle with the impossibility of eye contact over a video connection.
Paul: I know that texting and online chat has worked well for many mental health crisis services but some professional associations have strict limits on what online therapies their accredited practitioners can use as do insurance companies. Text and chat and blended technologies (or omnichannelled therapies as you refer to them) have not been given the green light. In terms of online therapy many of us are insured only to do telephone and video therapy.
Kate: The insurance companies will catch up, as will the organisations. We’re in a familiarisation period, since Covid-19 has forced this on the profession. I think everyone assumes the definition of ‘online’ means video now, which is a real shame.
Paul: Yes ‘online’ and ‘video’ have become identified in many people’s minds, though some therapists and clients find the technology of video calls distracting and prefer to use the telephone. At the beginning of the pandemic I think it’s true to say that many therapists were scrambling to quickly find trustworthy online platforms. In your considered view, what platforms are trustworthy to do online therapy on, and which ones are not trustworthy?
Kate: I have been working with a UK platform developed by NHS doctors and psychiatrists called ProblemShared.net since pre-lockdown. This e-clinic not only offers the suite of technologies we need right now but also secure note taking facilities and payment interactions from clients. I am Chair of Clinical Ethics for the company, so can categorically endorse them. The free platforms such as Zoom have filled a necessary gap during Covid, but you pay for the platform with your personal data (and that of your client). It’s a trade-off that renders many platforms unusable for mental health work.
Paul: I don’t recall ProblemShared.net being mentioned on your Covid-19 course so it’s good to know about that. But you did mention on your course Doxy.me and VSee. How trustworthy are they?
Kate: I will restate that free services have to be paid for somehow, and this is usually by selling your data (and those of your contacts (e.g. clients)) on to advertisers. It’s just how capitalism works now. The free platforms have been useful in crisis, but it’s time to rent a proper virtual consulting room now, such as ProblemShared.net.
Paul: Okay. One of the concepts I have been reading increasingly about is the ‘online disinhibition effect’. What does the research say about that?
Kate: Disinhibition is a double-edged sword – in the best scenario the clients are able to be more open to sharing when online which can make the work move quite quickly, but toxic disinhibition also exists as we see in the media regularly. Imagine a world with no social niceties demanded and you have the Internet. Donald Trump is most certainly disinhibited when he tweets.
Paul: Yes. On the other hand, the Open University course, ‘How to do counselling online: a coronavirus primer’ says they have “no evidence that the online disinhibition effect has a negative impact on the therapeutic relationship or on client motivation”.
Kate: Based on experience, I would ask what evidence was looked for – there are at least five types of disinhibition, so I don’t believe the research (if done) was necessarily asking the right questions.
Paul: Another concept in online therapy that is frequently mentioned is that of ‘presence’.
Kate: Often called telepresence, we teach practitioners to engage in the process to a level where the unnatural elements of therapy we are using (phone, laptop etc.) disappear and both parties are immersed in the process despite it being a technology mediated session.
Paul: Like being in the cinema. You’re in that world?
Kate: Similar – both parties travel emotionally to a shared part of cyberspace to do the work, so it’s a co-created space, unlike the cinema.
Paul: Okay. One final question: Boundaries are very important in face-to-face therapy. How does the therapist set boundaries in a virtual space
Kate: This is very important as there is so much more to consider. As well as the session such as what is and is not appropriate (particularly via video), we have boundaries to set around social media connections and between session contact, as services on the Internet are usually available 24/7 and this can be assumed to be true about the therapist’s availability.
Paul: Is there anything else you would like to add?
Kate: A final point I would like to make is around privilege during lockdown. My own learning has been facing my own privilege in having many private spaces available to me – and realising that many clients do not. We should also be cognisant that not everyone has had a bad lockdown experience – this way of life has proved positive for some people in addressing what was wrong in their life before Covid. Many more are isolated, lonely, and bereaved of course so I think mental health has a long journey ahead of it, but the Online Therapy Institute is pleased and proud to have been part of that from the start.
Paul: Thank you very much, Kate.
Dr Kate Anthony shared the following resources:
Paul Daly is an IAHIP accredited psychotherapist working in private practice and community-based therapy in Dublin.
Anthony, K. (n.d.). Covid-19 Telehealth course ‘Moving your practice online’. Retrieved 20 August 2020 from https://kateanthony.net/shortcoursementalhealth/.
Anthony, K., & Wilson, J. (2014). Cyber culture: Working and living in a digital society. Retrieved 20 August 2020 from https://www.onlinevents.co.uk/cyber-culture-working-and-living- in-a-digital-society-kate-anthony/.
Greenberg, G. (2020). Therapy under lockdown: ‘I’m just as terrified as my patients are’.
Retrieved 21August 2020 from https://www.theguardian.com/society/2020/apr/23/therapy-during-coronavirus-pandemic-lockdown-psychoanalysis-freud.
The Open University. (n.d.). How to do counselling online: a coronavirus primer. Retrieved 21 August 2020 from https://www.open.edu/openlearncreate/course/view.php?id=5039.